Even when men who have sex with men are aware of the risk of hepatitis C infection, they aren’t always confident in their ability to go against the expectations of their peer group.
Hepatitis C infection used to be a concern mainly for people who used injectable drugs. However, it’s become clear that sexual transmission of hepatitis C is not an uncommon occurrence, particularly among men who have sex with men (MCM). According to the US Centers for Disease Control and Prevention (CDC), roughly 1 in 4 people in the U.S. who have HIV are coinfected with hepatitis C. And while hepatitis C is treatable, the likelihood of reinfection in this population, unfortunately, is high.
Seeking to understand what motivates HIV-infected MSM to engage in — or not engage in – risky behaviors, as well as obstacles they may face in attempting to mitigate this risk, a team of Dutch investigators conducted a study consisting of lengthy interviews with 20 MSM with hepatitis C, 19 of whom also were living with HIV. Five of the men were undergoing treatment for hepatitis C at the time of the interviews, 4 of whom had been infected with the virus more than once.
The investigators were particularly interested in how knowledgeable the participants were about hepatitis C, how much of a threat they felt hepatitis C was, how they felt about having the virus, and whether they were taking any steps to reduce their risk of transmission. They discovered that, in general, the participants were not focused on the physical complications of untreated hepatitis C (liver disease), especially in conjunction with HIV, but were more apprehensive about the unpleasant side effects of hepatitis C treatment that were more common in the past than with today’s new medications.
Some of the participants believed they were not at great risk of acquiring hepatitis C because they didn’t participate in activities that they perceived as traditionally risky, such as group sex or certain practices that could potentially damage the rectal mucosa. While those activities do entail risk, it’s also possible to transmit hepatitis C during straightforward condomless anal sex. For this reason, some participants were wary of situations that they felt could lead to peer pressure to have sex without a condom.
“During group sex at a club, you are more likely to meet somebody with [hepatitis C virus] HCV, because you have sex with more men,” one participant said. “Also it is more likely to skip the use of a condom, especially near the end of the evening after 4 glasses of vodka. So I am eliminating that kind of group sex at those clubs. I am going 1 on 1.”
Other participants expressed wariness of online dating, particularly when it came to meeting men who indicate that they don’t always use condoms. “I can’t trust them, especially when drugs are involved,” one participant stated.
Men who had experienced severe and/or prolonged side effects from hepatitis C treatment found that their sexual desire and confidence plummeted, leading to a reduction in sexual activities that might have led to reinfection.
The burden of these side effects led participants to express the view that hepatitis C infection was equal to or even worse than HIV. Most participants did want to reduce their risk of getting reinfected with hepatitis C, but expressed doubt that they could do so for a variety of reasons, including the belief that reinfection was inevitable; that impulsivity precludes having safe sex; that condoms ruin the sexual experience; and that peer pressure and drugs, particularly in a club setting, are formidable obstacles.
The investigators feel that an emphasis should be put on providing MSM with an honest accounting of the potential complications of hepatitis C as well as a realistic assessment of their chances of reinfection. Not only should clinicians provide this information, but ideally hepatitis C virus-infected peers will do so as well.
Newer hepatitis C treatments entail fewer side effects than those MSM may have experienced in the past, reducing the of fear of treatment. For this reason, the study team suggests that risk-reduction strategies focus less on the burdens of hepatitis C treatment and more on helping men overcome their unwillingness to challenge the norms in their peer groups, such as drug use and condomless group sex.
Ms. Saloman is a health writer with more than 20 years of experience working for both consumer-and physician-focused publications. She is a graduate of Brandeis University and the Medill School of Journalism at Northwestern University. She lives in New Jersey with her family.